The lateral digital flap for Dupuytren's fasciectomy at the proximal interphalangeal joint--a study of 84 consecutive patients.

Fasciectomy is the most common operation performed for Dupuytren's disease. However, as the joint contracture increases, issues of skin deficiency following release become significant. For severe or recurrent disease dermafasciectomy is advised, but a digital transposition flap provides a viable alternative without the need for a skin graft for less-severe disease with moderate skin deficiency. A retrospective review identified 84 patients who had undergone this operation. The flap used was proximally based on the midlateral aspect of the finger allowing direct closure of the donor site. Ninety hands with 134 digits were operated on and 83% of the patients had a full correction. About 70% remained fully corrected at 1 year. All flaps were performed for proximal interphalangeal joint involvement. The mean pre-operative contracture was 34 degrees, corrected postoperatively to 5 degrees. The recurrence rate was 9%. Two percent of the patients had local infection but no flap necrosis was seen. A lateral digital transposition flap is a very stable operation for Dupuytren's disease with moderate skin deficiency and our patients achieved favourable results when compared to other studies that used local flaps combined with skin graft.

Eccrine porocarcinoma.

Eccrine Porocarcinoma (EPC) is an important and often overlooked differential diagnosis for the more common Squamous Cell Carcinoma (SCC). Thus, it is important for clinicians to recognize it and formulate treatment accordingly. A case report typifying the pitfalls in the diagnosis of this neoplasm in relation to SCC is presented.

Results of surgical treatment of Dupuytren's disease in women: a review of 109 consecutive patients.

PURPOSE: Dupuytren's disease is not as commonly reported in women as in men. Our literature search yielded only two such studies. The purpose of this study was to further examine the presentation and surgical outcome of Dupuytren's disease in women, including complications and to compare these outcomes to a similar cohort of men and to previous studies of Dupuytren's disease in women. METHODS: A retrospective case series review was undertaken, and we identified all women who were admitted for surgical correction of Dupuytren's disease since 1990. Comparison was made with men operated during the same period. Pre- and postoperative measurements for lack of extension at the metacarpophalangeal joint (MCPJ), proximal interphalangeal (PIP) joint, and distal interphalangeal (DIP) joint were made by the senior author. SPSS (Statistical Package for the Social Sciences, SPSS Inc., Chicago, Il) was used for statistical analysis. The t test was used to compare the two groups. RESULTS: One hundred nine women were identified, with 119 operated hands, out of a total of 657 patients operated. Comparisons were made with 548 men. The average age at presentation was 63 years in women, and there was no significant difference between the two groups. One hundred five of the patients had digital involvement. The little and ring fingers were involved most frequently. Thirty-four had involvement of the MCPJ. Mean preoperative contracture was 35 degrees . Mean postoperative contracture was 1 degrees . Proximal interphalangeal joint involvement was seen in 66 patients. Mean preoperative contracture was 42 degrees . Mean postoperative contracture was 7 degrees . Distal joint involvement was identified in only 4 digits. There was no statistical difference with the men as regards digital involvement and joint involvement; however, correction at the PIP joint was significantly lower. Fasciectomy was performed in 107 cases (90%), fasciectomy and local flap in 7 cases (6%), and dermafasciectomy in 5 cases (4%). The most common complication was digital nerve/artery injury (6 patients), and disease recurrence rate was 22%. These were statistically similar to the men. CONCLUSIONS: Dupuytren's disease is less prevalent in women but its symptomatic presentation is similar to that in men, with more severe involvement of the PIP joint and a similar recurrence rate. The surgical outcomes, however, were equivalent with regard to final contracture correction, recurrence, and complication rates.

Cosmesis and satisfaction after breast-conserving surgery correlates with the percentage of breast volume excised.

BACKGROUND: The cosmetic outcome after breast-conserving surgery correlates with psychosocial adjustment. Previous studies have shown that, among other factors, cosmesis is dependent on breast size and weight of the wide local excision specimen. This study assessed cosmetic outcome relative to a combination of these factors-the estimated percentage of breast volume excised (EPBVE). METHODS: The study group consisted of 151 women who had undergone breast-conserving surgery. All had previously completed a patient satisfaction questionnaire and an independent panel had assessed cosmetic outcome. Their mammograms were reviewed and breast volume was estimated. A validation series showed cone volume on the oblique mammogram to predict true breast weight most accurately (r = 0.93). RESULTS: Both subjective cosmetic assessment and patient satisfaction correlated strongly with EPBVE. Overall, when the EPBVE was below 10 per cent, 83.5 per cent of patients were very satisfied with their appearance and only 3.1 per cent were not satisfied, compared with 37.0 and 16.7 per cent respectively if the EPBVE was more than 10 per cent. However, tumour location in the breast was also an important factor; cosmetic outcome was worse for medial tumours. CONCLUSION: The percentage of breast volume excised was an important determinant of cosmesis and patient satisfaction after breast-conserving surgery. Calculating the EPBVE before surgery may help select women in whom breast reshaping or volume replacement should be considered.

Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction.

The aim of this study was to assess and compare the psychological outcome and satisfaction of patients whom underwent wide local excision, mastectomy alone and mastectomy with breast reconstruction. A total of 577 patients had different types of operations for primary breast cancer (254 (44%) had wide local excision, 202 (35%) had simple mastectomy and 121 (21%) had breast reconstruction). Psychosocial morbidity and satisfaction were studied retrospectively using self-evaluation questionnaires. The three different surgical groups were cross-matched into four different age group. Significant statistical differences existed between the three procedures regarding satisfaction and psychosocial morbidity (anxiety, depression, body image, sexuality and self-esteem) in favour of wide local excision followed by breast reconstruction. Greatest morbidity was seen in the mastectomy group. Patient satisfaction of cosmetic outcome and psychosocial aspects was greater with wide local excision than with breast reconstruction or mastectomy. However, since wide local excision is indicated in only a group of patients, breast reconstruction should be an option available to patients requiring mastectomy.

Subcutaneous mastectomy with implant reconstruction: cosmetic outcome and patient satisfaction.

AIMS: To assess the cosmetic outcome and satisfaction of patients who have undergone subcutaneous mastectomy (SCM) with silicon implant reconstruction and to investigate the factors influencing cosmesis. METHODS: A total of 101 patients who had had SCM implant reconstruction for treatment of primary breast cancer were assessed for cosmesis by a panel using photographic assessment. Satisfaction and sexuality were studied by a self-evaluation questionnaire. RESULTS: A good to excellent cosmetic result was achieved in 71 (70. 3%) patients (and in 85% of the group who had immediate insertion of the implant). Eighty-one patients (81%) were moderately or very satisfied (96% of the immediate reconstruction group were so). Factors found to influence cosmesis positively were submuscular insertion of the implant (P<0.001), the lateral incision approach (P<0.001) and immediate reconstruction (P<0.001). CONCLUSION: The findings of this study support the use of SCM with implant reconstruction as the simplest option in those advised to undergo mastectomy and who wish for reconstruction.

The psychological impact of immediate rather than delayed breast reconstruction.

AIMS: A retrospective analysis of the psychological advantages of immediate reconstruction (IR) against delayed reconstruction (DR). METHODS: A total of 121 patients who underwent different types of breast reconstruction were seen in the follow-up clinic and assessed for: anxiety, depression, body image, self-esteem, sexuality and satisfaction. RESULTS: Ninety-five percent of the patients who had IR preferred this technique and 76% of the DR group would have preferred IR. Anxiety and depression were decreased and body image, self-esteem and sexual feeling of attractiveness and satisfaction were significantly superior in the IR group compared with that of the DR group. CONCLUSION: Patients who had immediate reconstruction recalled less distress and had better psychosocial well being than those who had delayed reconstruction.

The cosmetic outcome in early breast cancer treated with breast conservation.

AIMS: To measure the cosmetic outcome of breast-conserving surgery and identify the factors which influence cosmesis. METHODS: A total of 254 patients with primary breast cancer treated by wide local excision, with or without radiotherapy, were subjectively assessed for cosmesis by a six-member panel using photographic evaluation and objectively by an independent observer using specific measurement. RESULTS: Good to excellent cosmetic results were achieved in 184 (72%) patients on panel subjective assessment and 201 (79%) patients on objective assessment. Good correlation (P<0.001) and agreement were found between the panel's subjective photographic assessment and the objective assessment. The main factors found to affect cosmesis negatively were: medially located tumours; weight of specimen; re-excision procedures; radiotherapy; small breasts and longer scars. CONCLUSION: These cosmetic results, combined with a low local recurrence rate following wide local excision, validate the operative method used.

Does cosmetic outcome from treatment of primary breast cancer influence psychosocial morbidity?

AIMS: To investigate any influence of cosmetic outcome on psychosocial morbidity in patients who have undergone breast-conserving surgery for primary breast cancer. METHODS: Cosmetic outcome was assessed both objectively and subjectively in 254 patients, aged 20-69 years, who underwent breast-conserving surgery for operable primary breast cancer,

Patient evaluation of cosmetic outcome after conserving surgery for treatment of primary breast cancer.

AIMS: To investigate patient self-assessment of and satisfaction with cosmetic outcome following breast-conserving treatment. METHODS: A total of 254 patients with primary breast cancer who had been treated by wide local excision (WLE) were assessed objectively for cosmesis. Patients then self-rated their own cosmetic outcome and satisfaction via a questionnaire. RESULTS: Seventy-two per cent of the patients stated that there was little or no difference between the treated and untreated breast. Patient satisfaction was high with 90.5% being <> or <> with their cosmetic result. There were very good correlations between the objective assessment and the patient self-assessment of the cosmetic result (chi(2)=77.98 P<0.001) and between the patient satisfaction and the patient self-assessment (chi(2)=122.65 P<0.001). CONCLUSION: This study shows very good cosmetic outcome with high patient satisfaction. These cosmetic results combined with a low local recurrence rate following wide local excision validate the operative method used.

Cosmetic assessment of breast-conserving surgery for primary breast cancer.

The goals of breast-conserving treatment are to achieve local control and survival rates equivalent to mastectomy and to preserve breast cosmetic appearance. This paper specifically addresses the different ways of cosmetic assessment by the observer (subjective and objective assessments) and by the patient (self-assessment), and the factors which influence the cosmetic outcome, based on a review of the current literature.

Merkel cell carcinoma of the skin.

Primary neuroendocrine carcinoma of the skin or Merkel cell carcinoma is an aggressive primary neoplasm. It is commonly seen in the elderly, on the head, neck and extremities, where it can mimic a benign or less malignant skin tumour. Pathological examination shows a generally dense growth of small dark cells, with immunohistochemical evidence of neuroendocrine differentiation. The microscopic appearance is very similar to metastatic oat cell carcinoma from the lung and this must be excluded by clinical means and appropriate imaging studies. In this study we present 13 new cases of Merkel cell carcinoma (the largest published series in the UK) and summarize 214 cases from the literature in which the survival data are given. In our series, 5 of 13 patients died from spread of the Merkel cell carcinoma. From this and other studies, it appears that early diagnosis and wide local excision may be the only way to prolong survival. No other adjuvant therapy has proved effective.

Caustic soda burns to the extremities: difficulties in management.

Alkali burns to the extremities are unusual, but they are also a cause of significant morbidity, often because of their late presentation. Their management centres around water lavage, burn debridement and split-skin grafting; there is controversy over the timing of surgery. Three unusual cases of caustic soda burn in adults, and the difficulties encountered in their management, are described, and the literature is reviewed.

Results of clinical assessment after primary digital nerve repair.

We have carried out a retrospective study of 88 consecutive digital nerve repairs in 84 patients who presented to this department between September 1989 and September 1991. 94% of the patients were operated on within 24 hours of the injury, and the nerves were repaired using magnifying loupes (x 4.5) 71 patients were assessed clinically 8 to 32 months post-operatively. 17% of the patients had excellent results, 51.1% good results, 22.8% fair results and 9.1% had poor results. Close correlation between age and recovery of sensation and between smoking and nerve recovery were found. Results were better in nerves that were cut cleanly (64.3% were excellent/good) than in crushed nerves (28.1%). Without the availability of an operating microscope, loupes give a satisfactory result in nerve repair, and this study compares well with reported series.